073407162-8-13-2024-52-CC-MPRE-D84QEY-20240813120706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407162
Report Date: 08/13/2024
Date Signed: 08/13/2024 12:07:18 PM

Document Has Been Signed on 08/13/2024 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SRIVASTAVA, SHALINI		FACILITY NUMBER:	073407162
ADMINISTRATOR:	SRIVASTAVA, SHALINI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 556-9265
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94582
CAPACITY:	14	CENSUS: 8	DATE:	08/13/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Shalini Srivastava		TIME COMPLETED:	12:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/13/2024 at 9:03am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Shalini Srivastava for an unannounced annual/random inspection. Present during the inspection was the Licensee, her adult helper and eight (8) preschool age children. Another adult helper arrived at 9:38am. Licensee lives in the home with her husband. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:30am – 6:00pm, Monday – Friday. The childcare operates in the detached converted in-law unit in front of the main home. ON LIMITS AREA: Entire Detached In-Law Unit in the front of the property and Area of the Backyard directly behind unit OFF LIMITS AREA: Entire Main Home, Remaining Area of Backyard and Garage ISOLATION AREA: In front of full bathroom The facility is a single story in-law unit owned by the Licensee. Licensee uses the side gate in the backyard leading to the street as the facility entrance. The unit consists of two (2) rooms, one (1) full bathroom, one (1) half bathroom, a full kitchen and a stackable washer and dryer. The inside of the unit was observed to be neat, clean with ample age-appropriate materials for the children’s learning and play. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee stated that all children bring their own food from home, but does provide an option to parents to have food provided for their children. All food that is brought from the children’s home was observed to be properly labeled and stored and all food provided by the Licensee was observed to be properly stored as well. All off limit areas in the unit are made inaccessible with closed doors. Licensee stated she does not transport children, there is one (1) dog that remains in the main home, and there are no firearms in the in-law unit or main home. Page 1 of 4

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 08/13/2024

NARRATIVE

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There is one (1) fully charged 3A40BC fire extinguisher in room two (2) by the entrance of the unit. There is one (1) working smoke detector in one room, one (1) working smoke/carbon monoxide detector in the other room and one carbon monoxide detector in the half bathroom. The unit is equipped with two heat/air conditioners that are placed just under the ceiling in both rooms making them inaccessible to the children in care. The backyard is fully fenced, clean, well maintained with ample age-appropriate materials for the children. Licensee only uses the portion of the backyard directly behind the unit.

The facility is operating within its licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and EMSA approved Pediatric CPR & First Aid has expired. Licensee provided proof of registration for a renewal course that will be held 8/18/2024. Licensee was instructed to send LPA proof of completion once the course is completed. Licensee’s Mandated Reporter training is complete and expires 8/2/2026. LPA obtained the fire/disaster drill log. Fire/disaster drills have been conducted and recorded within the last six (6) months with the last drill logged 3/6/2024. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted on the wall in room two (2). LPA obtained the children’s files, helpers files, and facility files. Through record review it was found that two (2) children in care were missing files and one (1) child in care was missing immunization records upon LPAs arrival.

Deficiencies Cited During LPAs Inspection
· Two (2) children present in care did not have a file at the home upon LPAs arrival
· One (1) child present in care was missing immunization records upon LPAs arrival

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's authorized representatives, and to Community Care Licensing Division (CCLD) within 24 hours by phone. Within seven (7) days of the incident, Licensees must submit the Unusual Incident/Injury form (LIC 624B) to CCLD. Licensee was reminded that any structural changes or additions to the home must be reported to CCLD. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented.

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 08/13/2024

NARRATIVE

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EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee Shalini Srivastava, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 08/13/2024

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Shalini Srivastava.

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 08/13/2024 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	One (1) child in care were missing immunization records upon LPAs arrival. Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee was able to obtain child's immunization record during LPAs inspection. Licensee will ensure that all immunizations are obtained and complete before the child's first day in care moving forward. Deficiency cleared during inspection.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Two (2) children present in care were missing an Emergency Card (LIC700) and LIC627 Consent to Medical Treatment upon LPAs arrival. Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee was sent documents during LPAs inspection. Licensee will ensure that all children's documents are obatined before the child's first day in care. Deficiency cleared during inspection.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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